AAOIC Supplemental Health Questionnaire
Orthodontic Treatment in the Era of COVID-19
If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:
Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms?
*
Fever (defined as above 100.4° F degrees)?
Yes
No
*
Chills?
Yes
No
*
Cough?
Yes
No
*
Sore Throat?
Yes
No
*
Shortness of breath and/or trouble breathing?
Yes
No
*
Persistent pain, pressure or tightness in the chest?
Yes
No
*
New loss of taste or smell?
Yes
No
*
Have you or others accompanying you to today’s appointment traveled outside of our local area or outside of the US within the past 14 days?
Yes
No
*
Have you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?
Yes
No
If yes provide approximate dates of illness
through
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment to a later date.
*
Patient First Name:
MI:
*
Last Name:
*
Parent/Guardian First Name:
MI:
*
Last Name:
Relationship:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*
Patient/Parent/Guardian Signature:
*
Date:
Used with the permission of the American Association of Orthodontists Insurance Company (RRG)